22 Vadeleine M. Leininger:

Theory

Or Culture Care Diversity and

Universality Madeleine M. Leininger (1927-2012)

Marilyn R. McFarland*

are is the essence of nursing and a distinct, dominant, central

and unijying focus.

Madeleine Leininger (Leininger &McFarland, 2002, p. 192)

CREDENTIALS AND BACKGROUND nursing at this university' Vith the Therapeutic n Psychiatri Nursing Center at their hospital. In 1960, she

bte one oi OF THE THEORIST

g ent was pub-

in Nursing, which lished in 11 languages (Hofling & Leininger, 19601

the first basic psychiatric irsing texts with Hofli

tled Basic Psychiatric Concepts Madeleine M. Leininger, the founder of transcultural

nurs-

ing and a leader in transcultural nursing and human care

theory, was the first professional nurse with graduate preP- aration in nursing to hold a PhD in

cultural and social

anthropology. She was born in Sutton, Nebraska, begin-

ning her nursing career after graduation from St. Anth0

ny's School of Nursing in Denver, Colorado, and the U.s.

Army Nurse Corps with a diploma in nursing. In 1950, she

earned a bachelor's degree in biological science from Bene-

dictine College in Atchison, Kansas, with a minor in phi-

losophy and humanistic studies. She then served as an

instructor, staff nurse, and head nurse on a medical-surgi

cal unit and opened a new psychiatric unit while director

of the nursing service at St. Joseph's Hospital in Omaha,

Nebraska.

While working at a child guldance honme in the .

staf 1950s in Cincinnati, Leininger discovered that ths lacked understanding ot cultural factors influencia ng the behavior of children. Among these children of diverse cul tural backgrounds. she observed difterences in responses to care and psychiatric treatments that deeplycon concerned

her. Psychoanalytical theories and therapy strategies d not seem to reach children who were from diverse cultund

backgrounds. She became inereasingly concerned that her nursing decisions and actions, and those of other staf, did not appear to help these clhildren. .eininger posed ques.

tions to herself and the st.afl about cultural differences

among children and therapy outcomes. She found few staf members who were interested or knowledgeable abou

cultural factors in the diagnosis and Ireatment of clients. A short time later, Margaret Mead became a visiting proles

sor in the Department of Psychiatry, University of Cincin nati, and Leininger discussed with Mead the potental

interrelationships between nursing and anthropol0gy

During the 1950s and 1960s, Leininger (1970, 1978) tden tihed common areas of theory interests and researcn u

between the disciplines of nursing and anthropolog), w

aided her in formulating transcultural nursing concep

theory, principles, and practices. As a doctoral student, Le

In 1954, Leininger obtained her master's degree in psy-

chiatric nursing from the Catholic University of America

in Washington, DC, and was then employed by the College

of Health at the University of Cincinnati, Ohio, where she

developed the first masters-level clinical specialist pro-

gram in child psychiatric nursing. She initiated and

directed the first graduate nursing program in psychiatric

*This chapter is dedicated in memory of Dr. Madeleine Leininger.

Dr. Madeleine Leininger on a visit to Madonna University, Livonia,

MI, circa 1999. Source: The Madeleine M. Leininger Collection on Human Caring and Transcultural Nursing, ARC-008, Photo 03, Ar- chives of Caring in Nursing, Florida Atlantic University, Boca Raton.

fasc

nger studied many cultures. She found anthropolog terest to

nating and believed it was an area that should be Or Inc

334

adeleine M. Leininger: Theory of Culture Care Diversity and Universaity CHA

ER 22 Made 335

on the iadsup people ot the astern nternational Society tor lluman Caring in 1978 0 hely nirses toeus on the study ot human care plhenea Leininger. 1988a, 19ssh, 199), She was the tiust tull tine president ot the American Association ot Colleges ot Nins

ng and one of the tirst members ot the American Acaley ot Nursing in 1975.

New Gunnea:

living alone with these ndige

th vears, she undertook an ethno She

to tUsCNÍ

on the (

irsing study in the villages (leininger

hserved the unique teatures of the cl

lber ot nmarked ditterences between 1West.

in tern cultures related to caring. health, and

i es. Fron her in-depth study and tirst

the iadsup. she continued to

einger's book, Nursing and Anthropologr: Tvo Worlhis

to Blend (1970), laid the toundation for developing the fiell of transculural ursing. the culture care theory, and eu turally based health care. Her next book, Tanseultra s: Concepts, Theories. and Practice (1978), icdentilied major concepts. theoretical ideas. and practices in transe tural nursing and was the first detinitive publication on

transcultural ursing. During tlhe next o0 years. Leininger established, explicated. and used the culture care theory lo study many eultures in the United States and worldwide. She developed the ethnonursing research method to lit an to be used with the theory and to qualitatively discover the

insider or emie view of cultures (1cininger. 1991: 1cininger &Metarland, 2002, 2006: Mctarland & Wehbe Alamah. 2015b, 201isb). lhe ethnonursing research method was the

frst open inquiry research method designed tor nurse

researchers to study and discover culture care phenomena

from the perspective of human science philosophy an through the lens of qualitative analysis (Leininger, 1978. 1985a. 1991, 1995; Leininger & Meliarland. 2002, 2000; Mclarland &Wehbe-Alamah, 2015b, 2018b).

ricnces with

er theory

ot culture

are theory)

and the.

re care diversity and universality

ethnonursing researeh method

1978 1991. 1995 Her esearrh

and theory have ditferences i

ursing

ents understand cultural

ealth, and illness. Sh was the major

iet to endOUrAge

Nnim ients and taculty to0 education nd practice. Her

Ndder to

Tute nursins

interest in developiung the tield ot transeul

a human care tocus sustained her tor

arsing with

than six decades.

in transeultural nursing was ottered in

the l'niversity ot Color. where leininger had

amointed Protessor ot Nursing and Anthropology.

he turst

course in

itiatei the Commi on Nursing and Anthropology

the American AnthropologUal Association in 1968

ed as its chair tor several vears (Leininger, 1991,

Leininger also initated and served as the director of

st Nurse Scientist Program (PhD) in the United

s when. in 1969, she was appointed Dean and Profes-

T o Nursing and Lecturer in Anthropology at the Uni-

NiY of Washington, Seattle, where she remained until

There she established the first academic nursing

nartment on comparative nursing care systems to sup-

urt master's and doctoral programs in transcultural nurs-

ng She initiated several transcultural nursing courses and nentored the first nurses in a PhD program with a tocus

m transcultural nursing. Under her leadership, the Uni-

Ersity of Washington was recognized in 1973 as the out- Sanding public institutional school of nursing in the nited States.

ln 1981, Leininger was appointed Protessor ot Nursing

and Adjunct Protessor of Anthropology and Director of Transcultural Nursing and also Director ot the Center tor

Health Research at Wayne State University in Detroit until her seni retirement in 1995. Dr. Leininger developed sev- eral transcultural nursing courses and seminars tocused on

caring and qualitative research methods tor baccalaureate, master's, doctoral, and postdoctoral nursing and nonnurs-

ing students. She also mentored many students and nurses

in transecultural nursing tield research and continued these

endeavors at various universities in the United States and

worldwide. In 1989, Leininger launehed the Journal of

Transcultural Nursing, serving as its tirst cditor until her In 1974, Leininger was appointed Dean and Professor ot ursing at the College of Nursing and Adjunct Professor of Athropology at the University of Utah in Salt Lake City.

S institution, she initiated the first master's and doc- rograms in transcultural nursing and established the Octoral program offerings at this institution (Leini-

retirement.

Leininger wrote or edited more than 30 books in her

lifetime and published more than 200 articles and 45 book

chapters plus numerous tilms, videos, 1DVDs, and research

reports focused on transcultural nursing; human care and

health phenomena; the tuture of nursing: and related topics

relevant to nursing and anthropology. During her career,

Dr. Leininger served on eight editorial boards and refereed

several publications and was actively involved with the

Transcultural Nursing Scholars Group and the development

of and contributions to her own website (www.madeleine

-leininger.com). She has remained known as one of the

oter Substantive courses focused specifically on transcul- nger, 1978). These prog ograms were the first in the world to

974, nger founded the 1ational Transcultural Nursing and remained an active leader in the orga-

R ng She also initiated and was director of a new nfacilitation office at the University of Utah. In

nroughout her lifetime. She also established the zation

theory, research rch, onsultatio UNIT IV Theories

andGrandTheories

and care writings,

nost crcative, productive, innovative,

and futuristic

research-based nscultural nursing content

and ideas to

honors for her lifetime professional

plishments, including

include an LHD from

Kansas; a PhD from the University of

ege

a DS from the University of Indiana.

many aNards and and academicand dynamic

addresses. She received

authors in nursing who provided new

and substantive

several hono Benedictine

N degrees ha

College in Achisn advance nursing as a discipline and a professi1On. n addition to theory development

and transculurd

nursing. Leininger had many lifelong areas of interest

and

CpertisC, including comparative cducation and adminis

ration; nursing theorics; politics; ethical dilemmas or

rsing and health care; qualitative research

methods; the

uture ol nursing and health care; and nursing leadership

As a certihed transcultural nurse and rescarcher,

Leininger

studied 15 individual and unique cultures; mentored or

superised approximately 200 master's and doctoral

stud-

es focused on transcultural nursing. human caring/care,

and related areas worldwide: and consulted with many

opio, Finlads a Indianapolis. In 197% aue and sigpi And and 1995, she was gnized for her he American Asse

of Nursing as its first all-time president.i the Russell Sage standing Leadership

Anthropology So ciety, fellow

iation of C eininger r

cant contribution to the

recevetin 19 and was a fellow in the American Acaderard of iursing, a fellow of the

American

Society for Applied Anthropology, and a fellow o e Royal

College of Nursing in Australia. Other affliatliationsGamma, and Scandinavian College of Sweden. She

served as a

included Sigma Theta Tau; Delta Kappa

Caring Science he in Stockhrrescarchers and institutions, especially those using her

culture carc theorv. Her culture care theory is used world-

Wide and continues to grow in relevance and importance

Tor the discover of culture care phenomena about diverse

cultures.

distinguished visiting scholar lecturer at 85

universities in the United

World.wide and was a VISiting professor at n and

overseas w

Wayne State Univer.universities. While at the Board of Regents Distinguished aculty Distinguished Research Award

in Teaching, and the Outstanding Graduate

tor Award. In 1996, Madonna

igan, honored her with its dedication of the I

Collection and a special Leininger Reading Ra outstanding contributions to nursing and the

ences and humanities. Leininger was honored as Legend of the American Academy of Nursing in 1998

Dr. Leininger's last works on the culture care the heory were publications in peer-reviewed professional Durnals. She co authored an interview for Nursing Science O

terly (Clarke et al., 2009) in which she discussed the hit

sity, she eceived Leiningcr lectured to anthropologists,

physicians, social

workers. pharmacists, and educators, and conducted research

with colleagues. She remained active in two disciplines and

contributed to nursing and anthropology at national and inter-

national transcultural conferences and association meetings.

Award, the the Presidents Excelence aculty Men- iversity in Livonia, Mich.

ger Book ing Room for her

Leininger worked to persuade nursing educators and practi-

ioners to integrate transcultural nursing and culture-specific

care cocepts based on research findings into nursing curri-

cula and clinical practices as critical for the future of all

aspects of nursing. Across seven decades of the discipline,

numerous nurses with doctoral degrees and many master's

and baccalaureate students have become certified in transcul-

SOcial sc

tural nursing. using Leininger's culture care theory through- out their work (Leininger, 1991, 1995; Leininger& McFarland, 2002. 2006; McFarland & Wehbe-Alamah, 2015a, 2018b).

Leininger established transcultural nursing courses and

programs to educate, conduct, and facilitate research about

transcultural nursing and health phenomena. As interest in

transcultural nursing and health care grew, Leininger (M. R.

McFarland, personal communication, 1996) delivered key-

note addresses annually and conducted workshops and consultations both nationally and internationally through- out her career. Her academic vitae included nearly 600 conferences, keynote addresses, workshops, and consultant services in the United States, Canada, Europe, Pacific Island nations, Asia, Africa, Australia, and the Nordic countries.

Educational and service organizations continued to request her consultation on transcultural nursing, humanistic car

ing, ethnonursing research, the culture care theory, and futuristic trends in health care worldwide.

Dr. Leininger gained international recognition in nurs- ing and related fields through her transcultural nursing

tory and future of transcultural care, the irsing

profession, and global health care. In 2015, she te

about her retrospective comparative study conducted in 2011 about three Western and one non-Western culture

(Old Order Amish Americans, Anglo Americans, Meai can Americans, and the Gadsup of the Eastern Highlands

of New Guinea) to obtain in-depth knowledge abou father protective care beliefs and practices with the god

to use that knowledge to provide culturally congruent

care (Leininger, 2015). She reported on culture care deci- sion and action modes of similar and diverse care findings

discussed with the informant fathers as potential ways they might integrate their cultural values and care prac

tices to help their sons. Leininger then began work on d

new culture care construct, collaborative care, which sik

Co-presented with Marilyn McFarland via a keynotevu

eocast at the 37th Annual Conference of Transculturi

Nursing Society in October 2011.

Aoleine M. Leininger: Iheory of Culture Care Diversity and Un cHAPTER22 Ma

CH

nger died peacefully on August 10, e Leininger.

ohraska. She continued to work until

337

002, 2006; McFarland & Wehbe- Alamah, 2015a, 2018D) ninger predicted that for nursing to be meaningful ana Terevant to clients and other nurses in the world, transcu al nursing knowledge and competencies would be impe Ve to guide all nursing care decisions and actions To

Cective and successful health outcomes (Leininger, 199

1996 Leininger & McFarland, 2002, 2006; McFarland

maha, Nebra

Ilaborating with colleagues on eoreher strbons lo seve eral projects

and publications in ongoing

legacy is her work prog-

on the einingers

re diversity and universal and in the

nursing that will continue to transcultural

of culhurec

yiet those

roughouther,

m she has mentored taught, and influ- m ijine of

accomplished career. & Wehbe-Alamah, 2015c, 2018b).

inger (2002a) distinguished between transcultural g and cross-cultural nursing, The former refers to

nurses prepared in transcultural nursing who are prepareuand committed to develop knowledge and practice n ranscultural nursing, whereas cross-cultural nursing rerers O nurses who use applied or medical anthropological con- Cepts instead of developing transcultural nursing theory and research-based practices (Leininger, 1995; Leininger & McFarland, 2002, 2006; McFarland & Wehbe-Alamah, 2015a, 2018b). She also identified international nursing and transcultural nursing as different. International nurs- ng occurs when nurses travel to or have nursing practice or service-learning experiences in other nations or coun- tries; however, transcultural nursing involves multiple cul- tures and has comparative theoretical and practice base foci (McFarland & Wehbe-Alamah, 2015, 2018). Leininger described the transcultural nurse generalist (now known as certified transcultural nurse-basic or CTN-B), as a nurse prepared at the baccalaureate level who is able to apply transcultural nursing concepts, principles, and practices that are generated by transcultural nurse specialists (Leini- nger, 1991, 1995; Leininger & McFarland, 2002, 2006; McFarland & Wehbe-Alamah, 2015, 2018). The transcul tural nurse specialist (now referred to as a certified trans-

cultural nurse-advanced or CTN-A) is prepared in graduate programs and receives in-depth preparation and mentor- ship in transcultural nursing knowledge and practice. The CTN-A has acquired competency skills through post bac-

calaureate education by having acquired research-based knowledge about selected cultures in sufficient depth to provide high-quality, safe, and effective transcultural nurs- ing care (McFarland & Wehbe-Alamah, 2015, 2018). The transcultural CTN-A therefore serves as an expert practi- tioner, teacher, researcher, and consultant with respect to select cultures. The CTN-A specialist values and uses nurs- ing theory to develop and advance knowledge within the discipline of transcultural nursing, the field Leininger pre- dicted must be the focus of all nursing education and prac- tice (Leininger, 1991, 1995; Leininger & McFarland, 2002,

TICAL SOURCES FOR THEORY

EORETICAL

ENTELOPMEN

aer's theory

was derived from the disciplinesof

ology and. 2002, 2006; Mckarland & Wehbe-Ala- and nursing

Leininger, 1991, 1995; Leini-

2015a, 20186).

She described

nursing focused on the comparative studv

fdiverse cultures and subcultures worldwide

atiyolog

transcultural nursing as

nhaior

area

of r

e to their caring values, expressions, and health sth respect te and patterns

of. behavior. e of the theory is to discover human care

ness beliets a

he purpose

.and universalities in relation to worldview, cul- d ial structure dimensions, and then to discover

turally congruent care for people of to providecultur

frent or similar cultures

to maintain or regain their

ing or health or to face death (Leininger, 1991,

t-being

e: Leininger

& McFarlan 2002, 2006; McFarland & Alamah, 2015a, :018b). The goal of the theory is to

oVe and to bvide culturally congruent care to people

is beneficial and will ft with and be useful to the client,

mt: or cultural group (Leininger, 1991, 1995; Leininger afarland, 2002, 2006; McFarland & Wehbe-Alamah, .2018). Transcultural nursing goes beyond an aware- state to one of using culture care nursing knowledge

ractice culturally congruent and responsible care

McFarland&Wehbe-Alamah, 2015c, 2018b).

Leininger stated that, over time, there would be a new nd of nursing practice that reflects diverse nursing prac-

is that are culturally defined, grounded, and specific to lide nursing care provided to individuals, families, groups,

ad institutions. She contended that because culture and e knowledge are the broadest and most holistic means to

cptualize and understand people, they are central and mperative to nursing education and practice (ILeininger, 91, 1995; Leininger & McFarland, 2002, 2006; McFarland Nehbe-Alamah, 2015c, 2018b). In addition, she stated anscutural nursing had become one of the most impor a1, relevant, and highly promising areas of formal study, 5arch, and practice because people live in a multicultural

UI(Leininger, 1988a, 1995; Leininger & McFarland,

2006; McFarland & Wehbe-Alamah, 2015, 2018). Leininger (1996) promoted a new and different theory

from traditional nursing theories that defined theory as logi- cally interrelated concepts and hypothetical propositions to be tested for the purpose of explaining or predicting an event,

338 UNIT IV Theories and Grand Theories tory, and the evironmental

ehomenon, or situation. Instead. Lcininger defined theory

as the s'stematic and creative discovery ol knowlcdge about

a domain of interest inmportant to understand or account for

SOmc unknown phenomenon. She belicved nursing theory

must lake into accoun creative discovery about individuals,

1amilics, and groups, and their caring. values, cxpressions,

belicts, and act ions or practices based on their cultural life-

71 to providc eltective, satislfying, and culturally congruent

care (1 cininger. 1991. 1995; Icininger & McFarland,

2002,

O6: Allarland & Wehbe- Alamah, 2015a, 2018b).

I cininger (199) developed her theory of culture care

divcrsitv and universality bascd on the belief that people of

dilerent culures can intorm and are capable of guiding

protessionals to receive the kind of carc they desire or need trom others C1lture is the pattcrned and valued lifeways of

people that intlucnce thcir decisions and actions; therefore,

the theor is directed toward nurses to discoverand docu-

ment the world of the clicnt and to use their emic (insider) icpoints, knowledge. and practices with appropriate etic

(outsidcr). as bases for making cullurally congruent profes- sional care actions and decisions (Leininger, 1991, 1995).

The culture care theory can be both inductive and

deductive and is derived from both emic and etic knowl-

Contex abstract and practice dimensione that can

Tho he theay Ch tematically to achieve culturally congruent be exanine 2015a,c, 2018b). It is the onlv focused on culture and care of

three theory-based culture care

acceptable care comes (McFarland & w it is possib care becaus

derived fro

Wehhe in nur ethnonUrsi

heoare ou

or

peoAiyerse and what is

se

culluremodes ol deciiactions that are rectly applicable in clinical reaching beneficial and satisfactory lifeways ultimately discover care-what is sally related to care and parative focus to discover different

nursing care practices

document, through he

generic an

(Leininger,

Leining

to support of the

pracliceebeng, e thcory health-and has an

integrate or contrastin with specific care based carin nursings co ory with the onursing method has ramalconstructs iep

nes

na beneficial care

tease out in-depth infor

information. Thus, these enablers tural health care assessments.

eration of new knowledge in nursing:

nant emic data and healh

he enablers first reason

ment, and s- the human

reason 1S to

construct or

sed also be u

. The theory can at culturally congruent, neaningful, and t

uide he d health care t edge and th-

ferent cultu

(Leininger, 1

McFarland & knowledge i

promote the

or disability,

over time (Le

USE OF EMPIRICAL EVIDENCE

hat care For more than six deca Leininger held

dominant, distinc cdge (1991. p. 33). Leininger (1991) encouraged nurses and others to obtain grounded emic knowledge fronm the pe0-

ple or ulture because such knowledge is more credible.

The theory is ncither a middle-range nor macro theory but

must be viewed holistically with specific domains of inter-

cst. Leininger bclieved the terms middle range and macroo

to be outdated in theory development and usage (Leini-

nger. 1991, 1995; Leininger & McFarland, 2002, 2006;

McFarland & Wehbe-Alamah, 2015, 2018). Indeed, the culture eare theory is the broadest holistic nursing theory, because it takes into account the totality and holistic per-

spective of human life and existence over time, including

the social structure factors, worldview, cultural history and values. environmental context (Leininger, 1988b), language

expressions, and folk (generic) and professional care pat-

terns. These are some of the most critical and essential

essence of nursing and the

ve, and ing feature of nursing (Leininger, 1970, 1988b.nger& McFarland, 2002, 2006; McFarland Nehbe that care is comnpleoften embedded in social structure and other 2015, 2018). She stated

fession needs

holistic cultuz

ture (Leininger, 1991; Leininger & McFarland held that diferent forms, expressions, and Dat were diverse, whereas Some were universal ( s f Leininger & Mckarland, 2002, 2006). Leinino

meanings of a

1991, 1995;

land & Weht

1995) found

asp

often embedd

quali 1990; Leininger & McFarland, 2002, 2006) usei

ca